A nurse is contributing to the care plan of an older adult client who has pneumonia. Which of the following interventions should the nurse include in the plan?
Encourage fluid intake of 2.5 L per day.
Assist the client to cough and deep breathe every 4 hr.
Encourage independence in completing ADLs.
Use an N-95 respirator when providing client care.
The Correct Answer is A
A. Encourage fluid intake of 2.5 L per day.
This is an appropriate intervention for a client with pneumonia. Increasing fluid intake helps to thin respiratory secretions, making them easier to cough up and clear from the airways. Adequate hydration also supports overall health and immune function. However, the nurse should consider the client's individual fluid tolerance and any comorbid conditions such as heart failure that may necessitate fluid restriction.
B. Assist the client to cough and deep breathe every 4 hr.
This intervention is also appropriate for a client with pneumonia. Coughing and deep breathing exercises help to mobilize and clear respiratory secretions, preventing complications such as atelectasis and pneumonia. However, the frequency of coughing and deep breathing may need to be tailored to the client's tolerance and respiratory status.
C. Encourage independence in completing ADLs.
While promoting independence in activities of daily living (ADLs) is generally beneficial for older adult clients, in the context of pneumonia, the priority is to ensure adequate rest and conserve energy for recovery. Depending on the severity of the illness, the client may experience fatigue and dyspnea, making it challenging to perform ADLs independently. The nurse should assess the client's functional status and provide assistance as needed while promoting independence to the extent possible.
D. Use an N-95 respirator when providing client care.
This intervention is not directly relevant to the care plan for a client with pneumonia. N-95 respirators are primarily used for respiratory protection against airborne infectious agents such as tuberculosis or certain viral infections like COVID-19. While standard precautions should be followed when caring for a client with pneumonia to prevent the spread of infection, including hand hygiene and appropriate use of personal protective equipment (PPE), an N-95 respirator is not typically indicated unless the client has a specific respiratory pathogen requiring airborne precautions.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. "I'll rinse my mouth after taking this medication."
Montelukast is taken orally and is not associated with the risk of oral thrush or other mouth-related side effects that would require rinsing the mouth after administration. This action is more commonly associated with inhaled corticosteroids, not leukotriene receptor antagonists.
B. "I'll use this medication when I get an asthma attack."
Montelukast is not a rescue medication for asthma attacks. It is a long-term controller medication used to manage and prevent asthma symptoms, not to treat acute attacks. Short-acting bronchodilators such as albuterol are used for quick relief during asthma attacks.
C. "I'll take this medication once a day in the evening."
Montelukast is a leukotriene receptor antagonist commonly used to manage asthma. It is typically taken orally once daily, usually in the evening, to provide 24-hour control of asthma symptoms and improve lung function. Therefore, the statement indicating an understanding of the teaching is option C.
D. "I'll decrease my sodium intake while I'm taking this medication."
Montelukast is not known to affect sodium levels in the body or require any specific dietary modifications, such as decreasing sodium intake. Therefore, this statement is unrelated to the use of montelukast for asthma management
Correct Answer is A
Explanation
A. Encourage fluid intake of 2.5 L per day.
This is an appropriate intervention for a client with pneumonia. Increasing fluid intake helps to thin respiratory secretions, making them easier to cough up and clear from the airways. Adequate hydration also supports overall health and immune function. However, the nurse should consider the client's individual fluid tolerance and any comorbid conditions such as heart failure that may necessitate fluid restriction.
B. Assist the client to cough and deep breathe every 4 hr.
This intervention is also appropriate for a client with pneumonia. Coughing and deep breathing exercises help to mobilize and clear respiratory secretions, preventing complications such as atelectasis and pneumonia. However, the frequency of coughing and deep breathing may need to be tailored to the client's tolerance and respiratory status.
C. Encourage independence in completing ADLs.
While promoting independence in activities of daily living (ADLs) is generally beneficial for older adult clients, in the context of pneumonia, the priority is to ensure adequate rest and conserve energy for recovery. Depending on the severity of the illness, the client may experience fatigue and dyspnea, making it challenging to perform ADLs independently. The nurse should assess the client's functional status and provide assistance as needed while promoting independence to the extent possible.
D. Use an N-95 respirator when providing client care.
This intervention is not directly relevant to the care plan for a client with pneumonia. N-95 respirators are primarily used for respiratory protection against airborne infectious agents such as tuberculosis or certain viral infections like COVID-19. While standard precautions should be followed when caring for a client with pneumonia to prevent the spread of infection, including hand hygiene and appropriate use of personal protective equipment (PPE), an N-95 respirator is not typically indicated unless the client has a specific respiratory pathogen requiring airborne precautions.
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